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How to (Un)pack for a Real Discussion About Abortion

The murder of abortion provider Dr. George Tiller on May 31st has resulted in a lot of conversation about abortion. It’s a topic frequently hushed, or spoken about more around its politics than the actual procedure, the experience itself and the real women who have abortions. So this increased discussion is certainly something potentially positive happening because of something horribly tragic. More discussion around anything which is or may be treated as unspeakable is always a good thing.

However, often in these conversations and news stories, language is used that's confusing or inaccurate, and some statements are made about abortion or women who choose abortion which are false, unrepresentative or misleading. And any of this can come from either “side” of abortion debates or discussions, due to political aims or motivations, ideological ideas or agendas or just out of plain old ignorance. Just like a whole lot of people don't know the finer points of open-heart surgery, a lot of people just don't know what goes on with an abortion procedure, especially from a provider's point of view. If inaccurate, misleading or ideologically-loaded language is being used, or myths are being held as truths, our communication and understanding is always going to be limited. And that’s never a good thing, unless we don't really want to understand something at all.

Let’s start with a few typical language issues. When the politics of abortion are discussed, often language is used in talking about abortion that doesn’t actually exist in the practice itself, that providers don’t usually use or have any practical use for, and some of which is absolutely meaningless or invented only to try and misrepresent abortion or pregnancy.

“Late-term abortion”

Plenty of you have probably heard the term “late-term abortion,” lately because Dr. Tiller was one of the few providers who provided abortions for women past 24 weeks. “Late-term” is a phrase that we don’t use in practice because it doesn’t mean anything solid, practical or medical. Even in common use it’s pretty meaningless: when some people say that they mean an abortion from the 20th week through the current legal limit (which in some states is up to 28 weeks), others mean the whole second trimester, and some are talking about abortions into a period of time when legal abortions can no longer even be performed (past that 28th week or less in some states) except when the life or health of the mother is in danger, as determined by her doctor.

Whether a doctor or healthcare worker is talking about a pregnancy that ends in a birth, miscarriage or with an abortion, we talk about the timing of pregnancy either in weeks (as in, labor and delivery usually happen around the 40th week) or in trimesters. The first trimester of pregnancy is from gestation (from the date of a woman’s last menstrual period) through 12 weeks, the second from weeks 13-28, and the third from week 29 until a full-term, which is generally considered to be between the 37th and 42nd week, even though some women may deliver earlier or later.

Viability is more of a legal term than one used in healthcare, and in legal use has been defined as a fetus “potentially able to live outside the mother's womb, albeit with artificial aid.” In other words, for much of pregnancy, even with amazing care and medical technology, a fetus cannot survive outside a mother’s uterus. But at a certain point, even if it has not fully developed yet, it can or may be able to.

What viability is considered to be, in terms of at what number of weeks, varies from state to state and has also changed over time. When Roe Vs. Wade was decided, viability was considered to be around 28 weeks, but since that time, it has changed in some areas or countries to be as early as 22 weeks. However, in practice, viability is generally determined more by unique development, like lung development (which will vary some from fetus to fetus) rather than by weeks.

An astute bit of commentary in the Wiki on pregnancy adds about the increasing time period of viability that, “Unfortunately, there has been a profound increase in morbidity and mortality associated with the increased survival to the extent it has led some to question the ethics and morality of resuscitating at the edge of viability.”

“Baby” is another term we don’t use in medical practice: it’s an infant or newborn when we’re talking about a live birth. Before birth, we are talking about an embryo, around two weeks after gestation, or a fetus, from the end of the tenth week of gestation onward. This language is not meaningless or just about semantics: we’re talking about very different phases of development when we talk about a zygote, a blastocyst, an embryo, a fetus and an infant. But for those of us working in abortion, embryo or fetus are the only terms we’re using: anything before an embryo is to early for a termination (and often even for a pregnancy test), and an infant at or post-birth is not something we ever see in our practice.

Conception is also not a term we use in abortion. We don’t have any need to argue when conception does or doesn’t start, or to use this term at all because it doesn’t give us any information we need. What we need to know is if a woman is pregnant, and if so, what the size (via an ultrasound) of the fetus or embryo is, and, for legal purposes, how many weeks pregnant she is based on that size and her last menstrual period.

“Partial-birth abortion”

This this is not a medical term, and there is no such medical procedure that exists by this name. Rather, it was a term invented by Douglas Johnson, the legislative director for the National Right-to-Life Committee in 1995.

We have a legal ban -- put in place during the Bush administration, and which remains in place now -- on something by this name, even though it has no meaning in actual practice. Incidentally, the law itself also contains some pretty strange language for a law or policy. (In fact, if you also click the link to Roe V. Wade on that page, check out how different the language is. It’s a pretty major difference.)

What people using this term usually mean is a termination which is done around or after the legal limit for elective (as in, chosen, and with no need for a doctor’s order) abortions. The actual medical practice often being called “partial-birth” is an intact dilation and extraction (an ID&X, which is very different than a standard D&E), which is almost exclusively done for health reasons, stillbirth or profound fetal abnormalities, and/or also if the mother or parents would like the fetus to remain intact (for their own emotional process or for burial) or an autopsy is recommended. I won’t go into depth here about all that procedure can involve, but now that you know the right term, you can look it up for yourself, or take a look here, here or here for some sound general information.

Abortion procedures done at this time make up less than 2% of all abortions every year: they are exceptionally rare. An ID&X is not usually the procedure used for second-trimester procedures, and never for first-trimester procedures. ID&X is a type of abortion procedure for women who, very late in the game (usually in the third trimester) discover that either their fetus has very serious problems, that their health or life will be or is in grave danger with a birth or continued pregnancy, and/or if a fetus was already was stillborn (had died in the womb). A termination done like this and at this time can spare the mother the physical risks and emotional pain of going through the rest of her pregnancy, then labor and delivery with an infant absolutely known to be born still (to be dead before birth), or which would die shortly after birth. An ID&X can also be done more quickly than an induced labor and delivery, and with life or health at stake, that’s another reason why it has sometimes been done.

“Abortion doctor”

I don’t know of anyone with a doctorate degree in abortion, nor of any programs where you can get a doctorate in abortion. “Abortionist” is also a problematic term for this reason. “Abortion provider” is the preferred term by most. Many doctors who provide abortions are OB/GYNs: they are obstetricians and gynecologists. Some nurses also administer medical abortions.

With those linguistic foibles cleared up, let’s take a brief look at some common statements you may have heard before the last few weeks, but may be hearing more of now. Nearly all of these statements are either false, misleading or only represent one group of women or one kind of experience while rendering another invisible. And all or some of them have been used by more than just one “side” of debates around abortion, too. Some of these phrases are used by those who are pro-choice (who support every woman's right to choose parenting, adoption or abortion, whichever a woman feels is best for her), some by those who are antichoice (who do not support a woman's right to choose all three of her options), some by both.

Some of the statements or my responses to them may make you uncomfortable. I don’t state or respond to them to vilify anyone, to call out one group any more than another, to put anyone’s rights at risk or to enable these statements or ideas. I make them because I think it is so important that we do our best to tell the truth about abortion and about women. All too often I hear even some pro-choice people who are not being truthful: sometimes out of ignorance, limited exposure to abortion and the diversity of women who terminate, sometimes because they seem to be trying to simply walk the party-line and limit talk to those situations or women where abortion is the least challenged out of a fear of losing our reproductive rights.

The thing is, when it comes to reproductive rights, choice and experience, something as simple as a glib party line is too simple, because women’s lives and reproductive experiences are not at all easily simplified. We cannot be easily reduced down to one or two groups when it comes to our experiences with pregnancy, any choice we make around a pregnancy, or mothering. Those experiences and situations are just much too varied for that.

If we deny or hide some truths – and usually the ones that challenge us the most -- I don’t think we’re helping anyone. If our rights are based on falsehoods, or are only about one group of women and exclude others, then they may not actually give everyone rights or be rights which are particularly solid, rather than arbitrary or mercurial.

In my responses to these statements, I’m coming at them from a few spheres of experience: from the decade and some I have run Scarleteen and talked with or read women talking about abortion, from the year and a half I have worked part-time at an abortion clinic (which provides abortions up to 24 weeks), from a lot of academic reading on the subject, both in terms of the medical aspects and the first-person experience of pregnancy, decision-making and abortion, as well as from my own life: my experiences and those of my friends and family.

No woman wants to have an abortion.

Many women, if not most, who choose an abortion want to have one. If a woman freely chooses abortion for herself, rather than being pressured or coerced into it, then an abortion is absolutely what she wants.

And let’s be real about that: women are pressured or coerced into all of the possible choices with a pregnancy with some frequency. Sometimes that pressure is direct, from family, partners, friends. Sometimes that also comes from communities, cultures, religions, politics. No matter WHAT choice a woman is making about her pregnancy, from a pro-choice perspective, pressure, coercion or force is absolutely unacceptable.

By all means, some women have pregnancies they do NOT want to terminate, where the last thing they want is an abortion, yet they still decide to terminate, usually based on very serious or grave circumstances. Some women feel that of the three choices available they don’t want to make any of those choices: but one has to be made, even if none of them are wanted.

There is a range in this: for some, abortion is an ideal choice, what is most wanted, full-stop and without any feelings of conflict. For others, neither abortion nor childbirth are wanted outcomes, but abortion is the more wanted choice and what seems best to that woman with her pregnancy. For many, feelings lie somewhere in between those two poles.

Every woman who chooses abortion does so with sadness, or finds the decision to abort one that is exceptionally difficult.

In the United States (and many other areas) abortion is legal. And there is no legal requirement that a woman must feel a certain way in order to have or retain the right to terminate her pregnancy.

There is no way all women feel with the end of every or any pregnancy: all women who terminate do not experience feelings of pain or deep sadness, just as all women who give birth do not experience bliss and perfect joy (a myth which is propagated just as much as the opposite around abortion has been). Women’s feelings vary widely with every pregnancy, every termination, every delivery. There is not a “right” way to feel with any of these choices, with any part or experience of pregnancy, nor if a woman does or doesn’t feel a given way is she any more or less entitled to her own choices with her pregnancy.

No woman has an abortion casually.

Just as the case is with the great range of experiences with how a woman feels about abortion, so it is with the motivation for, or decision-making process with abortion. Some women DO have abortions in a way you or I – or even they – might call or see as “casual.” For some women, having an abortion is not a big deal, is not upsetting, is not something she feels carries a lot of weight for her. It should also be noted -- though this is not to say if a woman is "casual" about abortion it is only for this reason -- that certain developmental disabilities, addictions, traumatic life experiences or psychological conditions can cause a woman to give any number of things, like death, abuse or pregnancy, less gravity than others might give them or feel about them.

Having talked to a lot of women about their abortions, would I say there are many women who feel casually about abortion or take it lightly? No, I would not: in my experience, that’s the exception rather than the rule. In fact, I think we can go one step further and say few women feel casual about a pregnancy, period. But again, we have to be very careful not to deny any woman’s real experience, even if the reason we might be tempted to do so is in an effort to try and retain her/our rights.

Abortions in the second-trimester are only done in cases of rape, incest or when the health of the mother and/or fetus are at risk.

That is not true. While in the third trimester, past viability, abortion procedures can only be done when the mother's life is at risk, this is not so for most or all of the second trimester. While second-trimester procedures are much less common than those done in the first trimester, many second-trimester abortions are chosen electively, and it is absolutely legal to do so.

Why do women terminate in the second trimester? Well, this is a big topic, because we’d need to address the myriad of reasons why a woman has an abortion at any time. We’d also be irresponsible if we didn’t explore why it is that second-trimester procedures are considered so different than first-trimester procedures by many people, even though that doesn't fit everyone's experience of pregnancy. So, I'll have to shortcut a bit here to avoid writing a thesis.

There are some common reasons why women do not terminate by the end of the first trimester, but in the second: because she didn’t accept or know she was pregnant until later (remember that not all women have regular periods, and some women experience bleeding during pregnancy they mistake for a period), because she couldn’t afford a termination until later, because she couldn’t get access to an abortion in her area earlier, because she originally wanted a pregnancy, but then changed her mind, often based on something major changing in her life (loss of a home or job, loss of healthcare, a natural disaster, another child or family member becoming ill or in need, loss of a spouse or husband or of a partner’s support for a pregnancy or child, a relationship becoming abusive or existing abuse increasing, etc.), and also because of maternal or fetal health issues or abnormalities (often these can’t be identified until later in a pregnancy).

If you want to know more about women who have had later terminations, some sites have recently been compiling first-person stories. RH Reality Check has a bunch here, and The Atlantic has a good round-up of some from their site here. And for general first-person abortion stories from women at all stages, the clinic I work for has kept a story archive for a long time right here.

If everyone had access to birth control and all the methods we had were 100% effective, all pregnancies would be wanted and we would have no abortions.

While some women have very firm and consistent feelings before and during the whole of a pregnancy that a pregnancy is wanted, not everyone feels that way. Given how much pressure expectant mothers are under to express nothing but joy about a pregnancy, we can’t even accurately say how many women have mixed or mutable feelings: we just don’t live in a world yet which allows women that kind of honesty around pregnancy.

Even if every wanted pregnancy remained wanted, we can be certain that many women would still want and need abortion. Life doesn’t just stay put while we’re pregnant, so our circumstances can always change, like some of the changes I talked about above, and some of those changes can seriously alter our plans, previous wants and needs or the status of our pregnancy. In fact, I think it’s pretty strange to talk about a process which is about nothing but constant change – for a developing, as well as for a pregnant woman – as if it could be unchanging.

That said, birth control access and efficacy is a huge issue, and given that in America alone, nearly half of all pregnancies which end in abortion are unintended, we know that lack of access to methods, not knowing how to use methods properly or having a lack of cooperation around contraception in sexual partnerships and the level of effectiveness methods provide does very much contribute to more abortion than we would see otherwise. Those earnestly looking to help reduce the number of abortions drastically should absolutely be working to increase birth control access, awareness and the development of reliable methods of contraception, since this is the one thing we know would make a huge difference which does not in any way diminish or remove women's reproductive rights.

Women who have abortions don’t like or love children.

In the United States around 60% of women who have abortions are already mothers; mothers who love their children no more or less than anyone else. Often already being a mother informs much of their choice: they know, after all, without having to guess, what parenting requires and what their children need, and if they can or cannot meet those needs. Lower-income women have always had more abortions than higher income, and that’s part of this piece, too: many women know when we cannot afford any children or are already finding it very difficult to provide care for existing children. Some women choose abortion in part or entirely out of love for the children they already have: they know when another mouth to feed and child to care for will make providing good care for all their children impossible.

There’s an old pro-choice slogan which is “If you can’t trust me with a choice, how can you trust me with a child?” It’s been pretty popular because it feels so true for so many women. When women make decisions around pregnancy, they usually are not just about either themselves or a child, but about the welfare of both. Mothering is not an easy business and mothers have to make choices for their children every day, often many times a day, and some of those choices are tough ones. Deciding to be a mother or not is one of those choices, potentially the biggest and most important of all of them.

Abortion is a bloody, ugly, brutal, painful -- insert any other words here used to make a surgery sound like a world war -- procedure.

I spent a lot of my childhood in a hospital: my mother was a nurse and a single parent, the hospital was often my after-school hangout, and I was a curious kid. I probably saw more blood and guts than most children do for that reason. I was also an adventurous child who got injured a lot: I severed two of my fingers when I was seven, scraped the mush of them off the sidewalk, and carried them rather casually back to our apartment. (Some of my ability to do that without flinching was likely shock, mind you, but some was probably because I was used to dealing with or seeing injuries.) I also personally have seen blood and violence in my personal life outside medical situations, and have lived through a few incidents of brutality, as have other members of my family. And I have observed a number of abortion procedures, both in the first and second-trimester. I’ve also had a termination myself, and did so only with a local anesthetic.

Certainly, to some people, any surgery seems or looks bloody and brutal, especially those who get queasy around this stuff. Too, not everyone can manage emotions well around blood and other things involved in surgery and healthcare.

However, ANY surgical procedure usually involves blood. Most involve pain or discomfort, either before, during and/or in recovery from the surgery, and when a surgery is not painful, it’s usually because anesthetic and/or sedation was used: some abortion providers offer both, others just one. Are abortions more bloody than most other procedures? No. More bloody or physically (or emotionally, though that, varies very widely from women to women and birth to birth) intense for a woman than childbirth? Not usually. I have to wonder sometimes if the people who call abortion things like bloody or brutal have ever witnessed a birth or even listened to honest accounts of birthing.

Are most women I have observed in horrible pain during their abortions? No. All of our pain thresholds vary, so what a woman experiences varies, but again, we’re not talking about a birth here (birth is usually painful, but we hardly suggest that's a reason women should not give birth), and remember, too, that most abortion procedures only take a few minutes, not hours and hours. Most abortions are not highly painful procedures, and pain can also be managed with medications, as with any surgery. While like other aspects of abortion, experiences of pain vary, some women even report that their monthly menstrual cramps or some sex they have in their lives had has been more painful than an abortion was.

I have yet to see an abortion procedure I’d describe as brutal or violent. As someone who has observed procedures first-hand, I’m always amazed by how many people who have NOT done so will tell me how things happen, or how awful everything is, apparently forgetting that of the two of us, I’m the only one who actually knows and has experienced how abortions are performed.

By no means is this an inclusive list of either the language used or misused with and around abortion or the various mythologies around abortion and women who have abortions. But it’s a place to start, and we truly are long overdue at even just starting truthful collective conversation about abortion. If we truly can do that, I strongly suspect that it can play a part in both reducing clinic violence and in everyone starting to see women’s lives more clearly, accurately, fully and compassionately.

(Like I said, I think good discussion around abortion is very important. If you're commenting, just please just bear in mind Scarleteen’s pro-choice policy and the guidelines around it. Any comments or questions which don't abide by our policies will be deleted or will not be published.)

Reading this caused a bit of free-association, and I realized there's one thing which doesn't seem to be well-known or much talked about which has been a particularly heinous result of anti-women reactionaries, and which is a pitfall for any pregnant woman. I'm sure you know it, but it seems not to be widely known, and reading this just made me think of it again.

Many OB/GYNs don't know how to perform any abortions nowadays, due to atrocious medical school policies -- as far as I can tell most hospitals used to require OB/GYNs to learn how to do D&Cs at least but in most places it isn't mandatory any more. The problem is severe enough that there's an activist group. http://medicalstudentsforchoice.org/

If you're a pregnant woman, you *need* access to doctors who perform all types of abortions. (This is the statement which I've never seen written out bluntly.) And you may well have to do some work to make sure you'll have that access. Even if you're absolutely sure you want to give birth, you may find yourself in a situation where your life is at risk and can best be saved by having some particular type of abortion -- most women will decide to live in that situation. But if your OB/GYN doesn't know how to perform abortions, and doesn't have a surgeon on call who does, you may be dead. (Your family would have a case for medical malpractice, but that wouldn't help much, would it?)

Very informative. As a guy in the United States, I am used to hearing all of the misleading terms and myths (really) about abortion that sometimes it's easy to confuse reality with imagination. I wish this information was more widespread and embraced nationally by our Department of Education. After all, this issue is by no means restricted to people who can birth a child, but to every single human being who cares about reproductive rights. If the government/the public starts telling people who possess the ability to give child birth what they can and can't do with their own bodies, what's to stop them from imposing restrictions on ANYONE'S bodies?

So much of this article rang true for me, though as a guy it will always be impossible to appreciate all the pressures that women feel in this area (the section "No woman wants to have an abortion" was very interesting).

I thought this was an excellent article, but I have a minor point of contention. I think that it's more or less true that "no woman wants to have an abortion." I don't mean that in the sense that no pregnant woman wants to have an abortion--clearly, many women in that situation DO want abortions, for any number of reasons--but I don't think that many women, if any, want to be in the situation where they would choose to have an abortion.

Well, for starters, once someone is actually pregnant if they don't want to remain so, abortion is what terminates a pregnancy. Sterilization prevents pregnancy: it can't make a pregnancy go away that's already happening.

That aside, sterilization is a choice to never become pregnant: abortion is a choice to terminate a pregnancy once, at the time. Sterilization also can be more expensive than abortion, people in their most likely reproductive years can't always be given one (many providers will refuse people in their teens or twenties), and not everyone wants to make a permanent choice about not having children.

the abouts:

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